Have At It

As I was fixing the wiring in my basement, a thought popped into my head about another way to decrease costs of medical care in this country.

Get rid of prescription requirements for most medications and procedures.

How many people would go to the doctor for a sore throat if they could buy a strep test over the counter? If the strep test is positive, they go to the pharmacy and purchase some penicillin over the counter.
If you twisted your ankle and could walk into a radiography center and get an x-ray of your ankle for $100, would you bypass the emergency department?
If you could buy your blood pressure medication over the counter, would you keep going to your doctor for those $150 checkups? Would you even purchase routine insurance? Or would you stick with just “major medical” coverage?

I know that issues would have to be worked out with an open access system – such as preventing narcotic abuse and preventing antibiotic resistance due to people taking Zithromax for the flu or Levaquin for their coughs. Maybe we’d have to limit the number of CT scans or angiograms that someone may receive to keep down the radiation doses.

You can purchase an HIV test or a pregnancy test over the counter. Why can’t you purchase a strep test or mono test over the counter? It’s not uncommon for medications once available only by prescription to go “over the counter.” Look at all the acid blockers and at Prilosec as one example. Why shouldn’t most prescription medications be available to everyone over the counter? If it isn’t a controlled substance, people should have access to it. What harm is avoided by having a medical provider as a “middleman”?

In almost any other situation, if I choose to take care of a problem myself, I can do it.
If I want to cut my own hair, I get a pair of scissors, look in the mirror, and start hacking. I don’t need a stylist’s prescription to purchase scissors.
If I want to sue someone, I can go to court, fill out the papers, pay the filing fee, and play the lotto. I don’t need a lawyer’s OK in order to gain entrance to the court house.
If I need to fix an electric outlet, I can go read about it online, buy the stuff at Home Depot, then hope I don’t get the red and the blue wires mixed up. I don’t need an electrician’s permission to purchase conduit.

When I get in over my head doing any of these things, I either take my chances or I call someone who knows more about the problem than I do.

Why should medicine be any different?

Think about it. If everyone had open access to medications, medical testing, and radiographic studies, there would no longer be an issue of what is and is not “necessary.”
If a patient wants a test, then the patient purchases the test.
If a patient wants medication, then the patient purchases the medicine. Be a lot fewer “designer” prescriptions being filled if patients had to pay full price for them.
With patients obtaining their own tests, there would be less medical malpractice for failure to order testing. The patient wouldn’t need a doctor’s order to get the test. Worried about breast cancer? Go have a mammogram done. Worried about lung cancer? Go get an x-ray … or a CT scan for that matter.

If patients get in over their heads, then they can seek the advice of someone who knows more about the problem than they do.

There will be a point at which people value the time they would spend waiting more than they value the few dollars they would spend just purchasing what they need. Is it worth it to spend 8 hours in the waiting room in order to get a $4 prescription for penicillin?
You could panhandle for a couple of hours and probably earn more than enough to buy a prescription at WalMart.

I wouldn’t allow antibiotics to be on this list. People can’t seem to get enough of them or understand the risks involved.

It doesn’t help that some older doctors ignore the evidence-based recommendations by giving a Z-pack to every runny nose. Cut antibiotics loose from prescription control and before long they would be useless against most infections and C. Diff would be killing millions a year.

Prescription requirements are like helmet laws. They protect people from their own stupidity. The physician should hopefully be a filter that sorts out the risks & benefits to decide whether a drug is OK.

High blood pressure? Just take some atenolol. Taking 400mg a day & still a little hypertensive? Keep bumping up that dose. Never mind the heart rate of 40 and the fact that you pass out every once in awhile. That’s probably just due to the high blood pressure. By the way, blood pressure cuffs work on top of a thick sweater, right?

Oh my…this post was very Happyesque. It’s also kind of ironic that you are advocating for people to have more access to medication & tests, when your blog is full of examples of human stupidity. Making simple tests available (like rapid strep) is one thing, but antibiotics or bp meds would be insane. LOL’s have enough trouble with the bp meds that are prescribed. Could you imagine what it would be like if they could just choose their own? Church would never be the same! ;-)

I say make Viagra over the counter (I guess you would have to have a big warning lable about how it is dangerous to take if you are on nitrates) – it would save jillions of urology visits! But I agree with the commenter above – definitely no antibiotics on that list. Hell, I would rather them just get narcs! It would diminish the visits to see me to feed their habit!

As a non-doctor, I have always resented having to go through a I-know-more-than-you-even-if-I-don’t gatekeeper to do medical things that I feel need to be done. Of course, I want to be able to engage an “expert” for advice and I want access to data. But why do I need a doc to get a prescription for Propecia? Why do I need a doc to get a lipid profile or adjust my statin dosage? As far as I can tell, an awful lot of medicine seems rather mundane. Looking back over the years, its hard to find situations where I was just blown away by the great advice I received for my family’s problems.

You need to lose the resentment of gatekeepers and “experts” because they do in fact know more than you (even if you think they don’t).

You want to know why you need a prescription for Propecia? Did you know the same active drug in Propecia is used to treat benign prostatic hyperplasia and prostate cancer? Did you know Propecia is a pregnancy category X drug and is readily absorbed through the skin? Therefore a pregnant woman handling a broken Propecia pill could cause severe defects to the genitalia of a male fetus. Do you have any idea how Propecia causes these effects?

You think an awful lot of medicine is rather mundane? I suppose 4 years of medical school and 3+ years working 80+ hour weeks of residency in your specialty doesn’t teach you anything that isn’t common knowledge already.

You clearly fall under the category of someone who “doesn’t know what he doesn’t know”. While it would be interesting to let people in this category play doctor and “do medical things that they feel need to be done”, they would end up harming other people in addition to themselves. Think of a person self adjusting their blood pressure medications and then passing out…while behind the wheel of a car.

Yes, there almost certainly are some medications that currently require prescription but will be deemed safe enough to be OTC in the future, but it is better for the FDA to start out conservatively rather than letting anyone who thinks they know more than their doctor to get their hands on every new drug that is approved.

You’re right. All medical knowledge should be locked up and kept secret, so that only a handful of Truly Responsible Men know about it. It’s just too dangerous to trust the public with the ability to treat their own medical problems. Here’s to the Doctor Priesthood.

“You want to know why you need a prescription for Propecia? Did you know the same active drug in Propecia is used to treat benign prostatic hyperplasia and prostate cancer? Did you know Propecia is a pregnancy category X drug and is readily absorbed through the skin? Therefore a pregnant woman handling a broken Propecia pill could cause severe defects to the genitalia of a male fetus. Do you have any idea how Propecia causes these effects?”

Do you see that big black box on the Propecia package that says “pregnant women should not use Propecia or handle Propecia tablets”? That’s really all you need to know, isn’t it?

It’s not like we don’t deal with hazardous, potentially-fatal materials ALL THE TIME. I mean, gasoline is deadly poison if you drink it, and it’s not healthy for you to have regular skin contact or even to breathe the fumes, and yet somehow Grandma Beaker is permitted to fill up her own tank.

Where did I state medical knowledge should be kept secret and in the hands of “Truly Responsible Men”? You can buy the exact same textbooks medical students use to learn and read to your hearts content. Just don’t delude yourself into thinking because you read up on how one disease process works that you know better than your doctor. Medical school and residency training is an extensive process and you can’t just substitute a few hours of reading up in your spare time and declare yourself competent to manage your condition. By the way, have you looked at recent medical school graduates? Medicine is hardly a field restricted solely to men.

I’ll ask again: Do you understand what the mechanism of action is for Propecia? Using google and telling me it is a type II 5-alpha-reductase inhibitor doesn’t mean you understand what that means. If you think knowing the mechanism isn’t important and the black box warning or any other warning insert included with the medication is “really all you need to know”, you are mistaken.

If you were to place 3 glasses in front of someone and fill one with water, one with orange juice, and one with gasoline, I’m pretty sure the average person with no medical training could tell you which one wasn’t safe to drink. Even if they couldn’t tell you before hand, it would become clear once they attempted to drink the gasoline. However, if you placed 3 bottles of medication in front of the same person, do you really think they would be able to tell you which one wasn’t safe for them to take? You can’t observe that people don’t harm themselves by drinking gasoline and therefore conclude they won’t harm themselves by taking a pill they shouldn’t be.

“Where did I state medical knowledge should be kept secret and in the hands of “Truly Responsible Men”?”

How about when you said:

“While it would be interesting to let people in this category play doctor and “do medical things that they feel need to be done”, they would end up harming other people in addition to themselves.”

“I’ll ask again: Do you understand what the mechanism of action is for Propecia?”

No, and I DON’T NEED TO, just like I don’t need to understand exactly what sort of bad things gasoline would do to me if I drank it. The black-box warning says that pregnant women shouldn’t mess with it. Is there some extra layer of protection that I’d get from knowing the mechanism of action?

Seriously, I don’t understand what you’re trying to say, here. If I don’t do the proscribed action, then what does it matter whether I spent oh-so-many-years in medical school or I just read the label?

I’ll clarify for you. Patients should absolutely be educated on their disease process (as much as reasonably possible), what lifestyle modifications may be beneficial and what drugs are available to help them. Now, you could find all of this information in a textbook without ever speaking to a physician, but this does not mean you should be allowed to practice medicine (even if only on yourself) by self diagnosing serious conditions and deciding what prescription medications you should be taking.

Yes, you do need to know the mechanisms of action if you want to be the one deciding what prescription drugs you will be taking. The body is incredibly complex and we learn more about how it works every year that goes by. In case you havn’t figured it out, drugs have an effect at many sites in the body other than the intended target site. You need to understand what the side effects will be and how it will interact with other drugs you might be taking.

“Seriously, I don’t understand what you’re trying to say, here. If I don’t do the proscribed action, then what does it matter whether I spent oh-so-many-years in medical school or I just read the label?”

I don’t understand what you are trying to say here either. When the FDA deems a drug prescription only, it is because if it is used improperly, it can be extremely dangerous or even lethal and therefore only someone trained and licensed should be allowed to determine who should be taking it. In other words, it is the FDA’s big flashing warning sign to you that you aren’t qualified to determine if you should take the drug. If you heed this warning and only take prescription drugs under a doctors orders, you’ll most likely be fine. However, your (along with NormD’s) entire attitude seems to be to hell with the FDA warning, I know enough to decide what drug I should take.

All I’m saying if you are going to have that attitude, you better have “spent oh-so-many-years in medical school” or else you are going to find out what “bad things” can happen.

“this does not mean you should be allowed to practice medicine (even if only on yourself) by self diagnosing serious conditions and deciding what prescription medications you should be taking.”

Why not? As the patient I am ultimately responsible for my care. In any case, if I really want the care, I can probably find a doctor willin g to provide it.

“Yes, you do need to know the mechanisms of action if you want to be the one deciding what prescription drugs you will be taking.”

I think you just excluded many GP’s. Oops. Pharmacists are the ones who know how the drugs work (if anyone does outside the labs…)

Here’s the issue, I go to my doctor for three reasons:

1. Management of chronic issues. Prescriptions (renewals, dosage changes, med changes), labs, etc. In these cases I know as much or more than the doctor. I have to see the doctor because I need a script for the med or test for the condition I’ve had for years.

2. Injuries. Standard routine = make an appointment for a problem doctor can’t diagnose, sent out for imaging that doctor can’t read, make another appointment for a condition doctor can’t treat, at which point doctor says make appointment with specialist X who requires referral to treat. Rinse, lather, repeat.

3. Something novel for which GP knowledge is useful (extremely rare).

I could save my insurance company a lot of money and myself a lot of time and aggravation if I didn’t need to see a doctor for numbers 1 and 2. Or I could get a catastrophic coverage plan and pay out of pocket for most of my expenses and come out ahead even with chronic medical conditions. However, there would be fewer doctors….

“else you are going to find out what “bad things” can happen.”

I have never had a doctor refuse to prescribe any medication that I requested. I am more aware of the bad things than the doctors are because in the end, I suffer the side effects.

It is illogical to require prescriptions for most medications but allow others to be purchased. 20 extra strength tylenol can be a lethal dose but you can get bottles of the stuff OTC. Alcohol, just be 21. Tobacco, age 18.

“Why not? As the patient I am ultimately responsible for my care. In any case, if I really want the care, I can probably find a doctor willin g to provide it.”

So lets say your brother Dave is a diabetic and hes dropping off your nieces and nephews for babysitting over the weekend. You say hey Dave, let me check my blood sugar, and sure enough its a bit high. Well Dave, just leave me a few of your diabetic medications that work so well for you so I can get my blood sugar under control too. So who is going to be watching your nieces and nephews when you are in a hypoglycemic coma? You need to think beyond yourself. Other people can be harmed when you don’t use medications properly. And yes, it should be fairly easy to find a doctor willing to provide you with drugs for your diabetes, hypertension, or high cholesterol etc, but that doctor will be giving you the 1) the correct medication and 2) at the correct dose, two fairly important concepts.

Yes a GP decades out of medical may not be as sharp as they once were when it comes to drug mechanisms, but make no mistake, they were taught the mechanisms in medical school. As graduates of medical school, I’m sure they have a healthy respect for the complexity of the the human body and are not going to be prescribing drugs that they shouldn’t be. Yes, a pharmacist knows some things about drugs that doctors aren’t taught and your doctor knows some things about the body that pharmacists aren’t taught. However, they are both looking out for your safety, why would you only want one? It would be like declining to wear a seatbelt because your car has airbags.

As for your #1, I sincerely doubt you know more about dosage changes, med changes, or labs than your doctor. You don’t become an expert in medicine by observing what your doctor orders for your chronic condition a few dozen times or so. I can drive a car and can even pump my own gas, but I wouldn’t pretend for a second that I knew more than a mechanic, let alone try to rebuild a transmission myself.

#2: Like I said the body is complex and even doctors can’t fix everything and anything alone. Maybe we should go back to the days when treatment for an acute MI was to put you into a dark room and avoid any exciting stimulus. No pesky cardiologist needed.

#3:You are taking for granted that your GP has many years of medical training and likely decades of experience and that vast knowledge base is ready to be tapped at your request in exchange for a nominal fee because it would be “extremely rare” that you will require it? Really?

Yes, your doctor didn’t refuse to prescribe you the medication you requested, but not before verifying the prescription was indeed indicated and wouldn’t interfere with any other medications you were taking and that you had the correct dose. Do you think these are not important somehow?

“It is illogical to require prescriptions for most medications but allow others to be purchased. 20 extra strength tylenol can be a lethal dose but you can get bottles of the stuff OTC. Alcohol, just be 21. Tobacco, age 18.”

You can buy a bottle of 200mg ibuprofen pills OTC, and maybe you take 3 pills to control your aches and pain. Wouldn’t it be nice if there was a 600mg pill and you could just take 1? Well turns out there is, but if you want the 600mg pills it is prescription only. Why? Because people are much more likely to harm themselves taking the 600mg pills. Why can’t you just accept that the FDA has determined more people would be harmed by 600mg ibuprofen being OTC than would be helped?

As for alcohol and tobacco, thats a whole other issue. They have become so ingrained in our culture that it would probably be impossible to make them illegal (see prohibition). As a compromise, we pass laws meant to protect other people from being harmed when you engage in using alcohol or tobacco (drunk driving laws, no smoking in restaurants etc).

During my last year of pharmacy school, I actually did a whole presentation on drugs that could possibly be moved to “BTC status” – Behind the Counter. Many countries make a number of different medications available without prescription – but they require a patient to speak with the pharmacist to ensure that the medication is actually needed. These included things like some antifungals (Diflucan, Penlac), some antivirals (Zovirax cream), Epi-Pens, Albuterol inhalers, Zocor, allergy medications (i.e. Flonase, Nasacort, etc.). Some medications could also be moved to straight OTC status – notably things with similar medications that are already OTC – Allegra, all other PPIs (to follow the lead of Prilosec and now Prevacid) … and I’m sure that there are plenty more that I’m forgetting.

My presentation was a few years ago now, so I’m sure I’m leaving out some potential candidates for inclusion, but other countries (notably the Canada, Australia, New Zealand, and a lot of European countries – UK, Germany, Italy, etc.) have done this successfully. It may or may not be the answer, but I think it’s one that should be considered seriously if we’re looking to cut health care costs in this country.

Ok…this might barely work in a more sophisticated, planned culture, that is better informed or perhaps even smarter, etc, etc.

But in a country like the US, where the LCD (lowest common denominator) rules the roost, and is trumpeted/catered to by the media, politicians,and business, this puts the onus on them. And the ‘everyman’ doesn’t know what the right thing to do is, especially when its not common sense, and there is a huge body of specific knowledge that takes a long time to master… just to begin to understand the complexities.

It’s not necessary to prevent people from hurting themselves for this to be a good idea. It’s only necessary that more good comes of it than bad. Would more people have access to medicine they need, and not misuse it, than would harm themselves by misapplication of medicines?

Most of these meds aren’t as dangerous as driving to work, and we still let people have cars. The difference is, with a car you can hurt someone else, too.

There are plenty of drugs that could be moved to OTC or BTC status, but what this all comes down to is bureaucracy.

I will agree with the posters who noted that abx should not be on the list, I agree 110%.

Matt, stop taking every post literally, and dissecting analogies many things are written figuratively. I know you feel macho by throwing around your law wisdom on a medical blog, but save it for your own kind.

I cannot comment on USA regs at al but i do think a lot more thingss here in Uk should be available OTC or with pharmacist consultation. I suspect it’s the way things are going here to releive a bit of the burden from GPs.

I’m no medic but deffo no antibiotics, nothing like antidepressants, etc, but things like conjunctivitis should not warrant a script. I can buy cystitis meds but not conjunctivitis meds OTC. I can drown in linctus containing chloroform for 99 UK pence per 200ml. I don’t believe it is about protecting the public.

I remember last year in Australia pharmacies were banned from selling anything other than paracetemol and ibuprofen liquids and saline nasal sprays for children under 2 years of age because apparently in the USA they’re available in supermarkets and kids were getting ODed. Even before we were banned from selling the infant strength cold and flu liquids off prescription they were behind the counter, so a pharmacist was required to counsel the parents before selling the medicine.

Of course drug interactions are going to happen if people are allowed to buy medicine without being advised on correct use. =/

I honestly don’t understand how the American health system even functions, as poorly as it does.

The funniest thing? In many countries where I have lived (those with poor healthcare access), many more medications are available without a prescription. stuff like bp meds- they figure that no one would WANT to pay and take them unless they need them, and most people are given instruction by the their doctor (if they have one) or the pharmacist.

Look, people with diabetes already manage a complex disorder on a daily basis by themselves.

I think the prescriptions should be limited to drugs that are dangerous to society if used inappropriately (ie antibiotics because of resistance), not just dangerous to the individual.

As to the comment on drug interactions. Believe me, the best way to avoid this is not to take meds, and when people start paying the true cost they will be less inclined to pop pills without thinking. I have yet to have docs be particularly aware of side effects given my specific metabolic disorder or even drug interactions. At least the pharmacist catches the drug interactions.

“…people with diabetes already manage a complex disorder on a daily basis by themselves. ”

Ha. I am not permitted to purchase diabetic-treatment equipment without a rubber-stamp prescription from a specialist doctor. The only reason I go to see the guy is because I’m not allowed to write scripts or order tests for MY OWN PERSON. That privelege is reserved for the Medical Priesthood.

I’m a type II diabetic with HTN. I see my endocrinologist twice a year. For day to day management of my hypertension, I do it. I had to add a calcium channel blocker and fiddle with my beta blocker.

Now, I AM a physician. I’m a radiologist. I haven’t written a script for anyone besides myself in fifteen years. I used to call in to my PCP, and she pointed out that it would be faster and simpler if I just did it myself.

The FDA concluded their investigation and announced today that Prilosec can cut in half the blood thinning effect of Plavix (clopidogrel) and that “Patients at risk for heart attacks or strokes who use clopidogrel to prevent blood clots will not get the full effect of this medicine.” Thats the same Prilosec you held out as an example of a former prescription drug deemed safe enough to be OTC.

How many people taking these two medications would be aware of the drug interactions without the “middleman”. I’d say there is plenty of harm avoided by keeping the middleman in place.

How many doctors prescribing these medications know about the drug interaction? I didn’t.
How will doctors change the doses of the medication? Doubt that they will until Sanofi comes out with new recommendations. Increase the dose and have a bad outcome without changes in the guidelines and then Matt comes knocking on your door.

However, as a former pregnant woman I still can’t quite figure out why my doctor made me take a pregnancy test through his lab to “confirm” the home test I had already taken plus my description of morning sickness… I needed to see a doc right away to replace some of my meds for more pregnancy-friendly ones, so had to play his game.

This discussion gives me visions of giving my child a home strep test, calling the doctor with positive results, and being told to come in and “confirm” rather than just being sent to the pharmacy.

I agree with all of the above posters that letting the general public have free access to antibiotics would be irresponsible on many levels. For me personally it would be foolish as I have several drug allergies and contra-indications. However, if we can have the home test please take us at our word that far and treat per the results unless there is a darned good reason.

When you came in and told your doctor you had a positive pregnancy test, that would be a subjective finding in the medical world. Confirming the test through his lab would be an objective finding. It’s not that your doctor doesn’t believe you specifically, but a patient’s statements can be false , whether intentionally or inadvertently and must be verified when possible. Your doctor might also have wanted to get an idea of how far along you were based on your beta HCG levels, which his lab, but not your home test, would show.

In regards to the home strep test, here is the problem. You are presumably a rational person who wouldn’t lie to their doctor about a strep test, but other people would. Lets say doctors would take your word for it and give you the antibiotic prescription without confirming the test. People want antibiotics for lots of things that they don’t help with such as colds and the flu. Once word got out that you could simply claim you had a positive home strep test and get antibiotics, people simply would lie to get the antibiotics they want. People would essentially have free access to antibiotics and all the problems this creates would follow.

So the choice is do we confirm the test or do we allow free access to antibiotics?

Good point, Xhy. Also, it’s very likely that many will fail the strep test simply because they didn’t follow the instructions.

The google med degree has given people the idea that they can doctor themselves. It’s great to learn more about your conditions, but there has to be some trust that your doctor knows more about the overall big picture. Unhappy with your doctor’s approach? Find a new doctor. But, don’t start messing with your own medications. As a nurse I wouldn’t even feel comfortable doing that (though, I’d ask plenty of questions!). :-)

I agree that there will always be a problem with sensitivity and specificity of testing, but that problem already exists in the doctor’s office as well.
As for keeping inappropriate antibiotics out of the hands of conniving patients, MV has the right idea – if a patient wants antibiotics for nasal congestion, they will just go to a physician who inappropriately prescribes the antibiotics. Enough paying patients leave the good docs and go to Dr. SterileSnot and it puts pressure on competent physicians to either prescribe the antibiotics or lose the paying customers.
I personally don’t think that doctors are very good gatekeepers of inappropriate prescriptions.

“I personally don’t think that doctors are very good gatekeepers of inappropriate prescriptions.”

If those who are educated to prescribe aren’t keeping watch, then what do you expect will happen if all have access? Yes, people can get what they want if they search hard enough; but with the current system, most stick with one doctor and accept what they are given. Sure, they may google this & that, question their doctor’s motives or knowledge, and mess with their meds at home. But, what do you expect will happen if the floodgate is opened? If I don’t have to go to a doctor to get my meds, why go? Who then manages the disease process? Google? The only way this works is if you are taking the “natural selection” approach. Problem will be that innocent people get hurt due to antibiotic resistance or injury when Grandma has a syncopal episode and wrecks her car (there was a special on lopressor at the pharmacy…).

I looked for data online, but was unable to find it.
Does anyone know about the antibiotic resistance rates in Mexico versus the US? Just curious.
Also found an interesting discussion about antibiotic resistance that took place more than 10 years ago on a message board. The more that things change, the more they stay the same.

I enjoyed your article. It seems the people that would “Have At It” are lacking something. Some of this could be avoided if a strong and trusting doctor-patient relationship was established. I just finished a good book called “Time to Care” by Norman Makous, M.D. With over sixty years of experience in the medical profession, he is an advocate for putting the doctor-patient relationship back in the forefront of health-care.http://normanmakous.com/